The art of the possible

A fine, measured piece of oratory from the president. But there is still tough work to do

“I AM not the first president to take up this cause, but I am determined to be the last.” Thus Barack Obama, late in the day, took his quest to reform America's expensive and flawed health-care system to the floor of Congress with a mighty speech that will surely stand as one of the defining moments of his presidency, whether it leads to eventual triumph or disaster. His is a bold ambition indeed; but this week the president looked a bit closer to fulfilling it.

Politics, as everyone knows, is the art of the possible; and there have been times over this ill-tempered summer when the idea of tackling a system that costs almost twice as much as any other rich country's, yet yields substandard results and leaves tens of millions of people with no health insurance at all, has seemed simply impossible. Mr Obama has to find a package of policies that is fiscally and politically moderate enough to win over a vital few Republicans to his side (and also prevent the defection of nervous conservative Democrats). But at the same time he has to keep the support of the leftish Democratic Party base, which wants to see a more expansive and costly set of reforms. He may well fail. But on September 9th the president for the first time laid out in some detail what such a plan might look like. Cleverly borrowing good ideas from both sides of the party divide, his proposals at least look like a plausible basis for agreement (see article).

The plan obliges everyone to take out health insurance while creating a tapering subsidy for poorer families to help them afford it. It also requires insurance companies to end various nefarious practices, such as refusing to insure people with existing conditions or cancelling their coverage just when they need it most. To pay for these long-held liberal goals (the cost is put at $900 billion over ten years), the president has committed himself to several policies that Republicans, if only they could remove their partisan spectacles, should applaud.

There is, for instance, a tax on insurance companies that offer “Cadillac” plans to richer individuals; since this will inevitably be passed on to consumers, it is a useful step towards making individuals aware of the cost of their coverage. He has made a cast-iron pledge that he will not sign a health bill that increases the deficit, and has promised automatic spending cuts if savings do not materialise. He wants to set up a new technocratic committee that could mandate changes to the hugely expensive Medicare system of health care for the elderly (an idea that cleverly takes such difficult decisions out of the hands of politicians, who have displayed a lamentable failure to grapple with them). And the president also promised conservatives reform of America's mad tort system. The risk of being sued pushes up costs, obliging doctors to practise “defensive medicine” in the shape of needless tests and procedures.

Give me public options, but not now

Still up in the air is the trickiest question of all: whether the government should create a “public option”, its own insurance provider, which people could use if they dislike what the free market has to offer. Medical insurers and most Republicans say a public plan would enjoy unfair advantages and destroy competition. Liberal Democrats say the insurers will not cut prices without it. Both sides have a point. This newspaper still thinks the best solution would be to keep the public option as a threat: to set up a formal provision in the bill whereby a public plan would be introduced in, say, five years' time if certain targets were not met. In his speech Mr Obama hedged his bets, sticking with the public option but signalling a willingness to compromise. This may come back to haunt him. But overall, this performance was a big step forward.